Compliance Guidance - Medicare Advantage
On February 3, the U.S. Department of Health and Human Services Office of Inspector General (OIG) released new Medicare Advantage Industry Segment-Specific Compliance Program Guidance (MA ICPG).
The MA ICPG updates prior guidance that was issued 27 years ago and is designed to work alongside the Centers for Medicare & Medicaid Services (CMS) regulations requiring Medicare Advantage organizations to implement effective compliance programs.
When combined with the General Compliance Program Guidance (GCPG) issued in November 2023, the MA ICPG provides a centralized source of voluntary compliance program guidance for Medicare Advantage, identifying areas of risk and strategies entities can take to reduce that risk.
Compliance Risk Areas
1. Access to Care (Network Adequacy and Prior Authorization)
Strategies include:
Quarterly update and third-party verification of provider directory information
Review claim submission volumes of in-network providers
Review, track, and follow-up on provider complaints
Perform time and distance analyses of contracted providers
Review trends in claims and prior authorization denials
Review any artificial intelligence or algorithm-based tools
2. Marketing and Enrollment
Strategies include:
Avoid deceptive marketing, including improper financial incentives that influence enrollment
Oversight of third parties conducting marketing on behalf of the organization, including review and approval of marketing and communication materials
Monitor enrollment volumes outside of AEP and verify eligibility for special enrollment periods.
Document fair market value determinations
Review, monitor, and ensure accuracy of payment data and recipients, including third parties
Provide marketing and enrollment compliance-focused training for agents, brokers, TPMOs, and employees
3. Risk Adjustment
Strategies include:
Implement audits of diagnosis data, before and after submission to CMS
Review reporting of high-risk diagnosis codes
Evaluate and oversee any in-home HRA or chart review programs
Investigate allegations of risk adjustment coding fraud
Education and training
4. Quality of Care
Strategies include:
Ensure the integrity of the data used for Star Ratings’ quality and performance measures
Ensure Medicare enrollees can access medically necessary care regardless of their location, identity, and other demographic factors
Ensure network avoids providers who are excluded by OIG or who have suspended licenses
5. Oversight of Third Parties
Strategies include:
Due diligence and risk evaluation on third parties before delegating Medicare program functions
Include compliance rights and obligations in agreements with third parties
Ongoing oversight of third parties based on risk evaluation
6. Compliance Programs Within Vertically Integrated Organizations and Other Ownership Structures
Strategies include:
Ensure compliance leaders have sufficient expertise and have access to senior leadership
Include MA functions in organization compliance risk assessments
Implement systems and processes to ensure medical loss ratio is accurately calculated and verified
7. Submission of Accurate Claims
Strategies include:
Assess exposure under the False Claims Act
